Culture and Mental Health in Liberia: A Primer 2017

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Culture and Mental Health in Liberia:

A Primer

2017

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WHO/MSD/MER/17.3

© World Health Organization 2017

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Contact for feedback and communication: Department of Mental Health and Substance Abuse at WHO (mhgap-info@who.int) or Sharon Abramowitz (saabramowitz@gmail.com).

Suggested citation: World Health Organization. Culture and Mental Health in Liberia: A Primer. Geneva, WHO, 2017.

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Preface

At the request of the Liberia Country Office of the World Health Organization (WHO), we have prepared a narrative review of the literature on mental health and psychosocial programs (MHPSS) in Liberia. This review focuses on relevant beliefs, help-seeking behavior, service utilization and both formal and informal resources for mental health. This report can provide some useful background for those unfamiliar with the local situation that hope to contribute to improving mental health services in the country.

In 2015, a team was assembled specifically for this task through the Health in Africa Working Group of the University of Florida. We would like to thank the many people who generously contributed their time and expertise: Patricia Omidian, Amara Fazal, Alexis Boulter, Michael Dehalt, Chelsea Lutz, and Heejin Ahn, who helped locate and review the literature, and draft, refine, and edit the text.

One year later, the WHO commissioned an update of the report to reflect the changes wrought by the Ebola epidemic and to capture relevant research published from 2014-2016, and to include new initiatives in Liberian mental health and psychosocial services. Special credit goes to Patricia Omidian (WHO Liberia) for commissioning the initial phases of this project and to Mark van Ommeren and Edith van ‘t Hof (WHO Geneva) for supporting the finalization of this document. A special thanks to Patricia Omidian, Ruth Kutalek, Cora Passanisi, and Darren L.

Domah for their valuable insights from the field. Amanda Gbarmo-Ndorbor of the Ministry of Health as well as John Mahoney and R Kesavan (WHO Liberia) kindly reviewed the pre-final draft.

In addition to coordinating the project, I reviewed the literature and edited the drafts and final manuscript. Producing this report has required a communal effort and all of the contributors worked intensively in the hope of making a contribution to the ongoing relief efforts and the long-term challenge of strengthening mental health services in Liberia.

Sharon Abramowitz, Ph.D.

Boston, December 14, 2016

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This primer to “Culture and Mental Health in Liberia” has been designed to provide to interested agencies and practitioners an accessible summary of the relevant literature on mental health and psychosocial support (MHPSS) in the Liberia context. It also helps establish a “history of the present,” or a recent history of international and Liberian national activities and challenges in the MHPSS domain in Liberia.

The report builds upon the framework for a literature review set forth in the WHO-UNHCR (2012) publication Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for Humanitarian Settings, which includes a template for desk reviews to summarize MHPSS information about an emergency-affected region or country.

Liberia is in the midst of profound social and cultural changes that are creating a complex environment for mental health and psychosocial needs and services. Since the end of the Liberian Civil War in 2003, a decade of post-conflict development has transpired which has seen an extraordinary investment in community-based mental health in some of the most resource- poor contexts in the world. It is impossible, to date, to know the impact of the recent West African Ebola epidemic’s powerful and tragic impact on Liberian lives, or how post-Ebola mental health and psychosocial support will change in the near future in the context of shifting trends. This report, however, should give interested agencies and practitioners a foundation for understanding the context.

This report reviews and summarizes the available literature on Liberian mental health and mental health services. During two study intervals from 2015-2016, searches were conducted of academic monographs, databases, and the expert technical literature for state-of-the art research relevant to mental health in Liberia across a range of subfields, including public health, psychology, psychiatry, epidemiology, humanitarian studies, anthropology, political science, economics, and regional and gender studies. No time limit or restriction of content was placed on the review. A wide range of topics were considered, from ethnic, social and cultural attitudes towards mental illness, to “post-Ebola syndrome.” The study was augmented through consultation with key informant interviews.

The first part of the review describes the general context with a focus on historical, geographical, demographical, economic, political, religious, gender and cultural factors essential to a basic understanding of Liberia and its people. The second part of the review focuses on mental health and psychosocial context. This includes a review of factors such as basic epidemiology of mental illness, common beliefs about mental illness, sources of distress, concepts of self, explanatory models, idioms of distress, help-seeking behavior, as well as the roles of different sectors in MHPSS and the formal mental health system. The third part of the review describes the humanitarian context, including experiences with past aid in the area of MHPSS.

There is a need for increased attention to mental health and psychosocial support (MHPSS) in Liberia. While Liberian mental health actors will know their country and cultural well, outsiders getting involved in Liberia’s mental health system need to have basic knowledge about the country, the people, and sociocultural aspects of mental health and psychosocial support in Liberia. Reading this primer will help ensure that new stakeholders in MHPSS will have a basic understanding of context to be more effective in their work.

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1. INTRODUCTION 1.1. Background

Less than 1% of Liberians have access to appropriate mental health services. In 2014-2015, Liberia and its regional neighbors Sierra Leone and Guinea struggled to contain the largest epidemic outbreak of Ebola Virus Disease (EVD) in known human history. As of 26 May 2016, there have been 28,616 reported cases of Ebola, with an estimate of 11,310 fatalities. The tragic toll of the Ebola outbreak has weakened many of Liberia’s post-conflict reconstruction gains in health and economic development achieved since the end of the Liberian war in 2003.

Prior to the West African Ebola epidemic, the Republic of Liberia was ranked 175 out of 189 countries in the 2014 UNDP Human Development Index, and struggled with extreme poverty, a lack of access to basic healthcare, governance and transparency issues, economic underdevelopment, widespread exposure to potentially traumatic events, a lack of infrastructure, and persistent societal violence. After years of governmental and NGO efforts to expand basic mental health and psychosocial services into primary health care in all fifteen of Liberia’s counties, the Liberian health sector has been particularly hard hit; of the 372 reported cases among Liberian health workers, nearly half (n=180) have died of EVD—one of whom was a recently trained mental health clinician. The disruption in the healthcare sector undermined significant gains in training, staffing, and supporting mental health-trained health professionals.

The loss of these clinicians is likely to undermine significant gains achieved in training, staffing, and supporting clinicians.

With the onset of new demands like post-Ebola syndrome (Kutalek 2014, Grady 2015), children orphaned due to Ebola, Ebola survivors’ reintegration, and the losses and potential traumatic events experienced in local communities during the epidemic, the impact of Ebola on local mental health needs and services is likely to be significant. Governments, NGOs, and international organizations such as the World Health Organization are collaborating to “Build Back Better” mental health systems in Liberia (WHO 2013, 2016a) after the Ebola epidemic.

The challenges are great, but commitment has been demonstrated by the government and international partners. Strengthening Liberia’s health systems capacities while meeting the immediate challenges of a still incomplete post-conflict transition requires the creation of health systems capacity at each level of the mental health system, from psychosocial support in the community to clinical treatment, from case reporting to epidemiological surveillance, to updated and expanded mental health policy and legislation, to mental health financing mechanisms that are sufficient to meet emergency-related and routine needs.

This report is intended to contribute by summarizing what is known about Liberian mental health/psychosocial support and Liberian mental health services and informal supports before and during outbreak. This includes a review of the literature and background information on basic epidemiology (where data is available), common beliefs about mental illness, explanatory models, idioms of distress, help-seeking behaviors, configuration of mental health services and the relationship between religion and mental health. This review is intended to inform short- term, medium and long-term efforts to improve mental health care and mental health services in

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Liberia by outlining social and cultural issues relevant to Liberian mental health care, identifying systemic gaps, and identifying recent and past innovations in the field of mental health and psychosocial intervention.

1.2. Methodology

The report builds upon the framework for a literature review set forth in the WHO-UNHCR (2012) publication Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for Humanitarian Settings, which includes a template for desk reviews to summarize MHPSS information about an emergency-affected region or country. This paper reviews and summarizes the available literature on Liberian mental health and mental health services and was conducted in light of the West African Ebola epidemic from 2014-2015. The authors searched Medline, Google Scholar, and other available databases to gather scholarly literature relevant to mental health in Liberia using a range of keywords in different configurations. Keywords included, but were not limited to: Liberia, Ebola, EVD, post-conflict, conflict, education, depression, anxiety, psychosis, schizophrenia, learning disability/disorder, MHPSS, mental health, mental illness, mental disorder, psych*, conflict resolution, community healing strategies, drug abuse, substance abuse, counseling, gender-based violence, epilepsy, neuro*, brain*, trauma, PTSD, psychosocial, psychiatric. This review was supplemented by consultation of key books and grey literature relevant to Liberia and consultation with key informants in 2016 who had been involved with MHPSS in Liberia from 2014-2016. The first part of the review describes historical, economic, sociological, and anthropological factors essential to a basic understanding of Liberia and its people. This includes discussion of demography, family structure, economics, and religion. The second part focuses on mental health and mental health services, with a review of factors such as basic epidemiology of mental illness, common beliefs about mental illness, explanatory models, idioms of distress, help-seeking behaviors, configuration of mental health services and the relationship between religion and mental health.

2. SOCIOCULTURAL CONTEXT 2.1. Geography of Liberia

Liberia is a sub-Saharan nation in West Africa spanning 110,000 square kilometers (43,000 square miles), of which approximately 87% is land. It is located on the North Atlantic Coast of Africa and is bordered by Guinea to the north, Cote d’Ivoire to the east, and Sierra Leone to the northwest. Coastal mangrove swamps, lagoons, and sandbars characterize the terrain. The interior is dominated by dense tropical rainforests covering rolling plains and a rolling plateau, with low mountains in the northeast. The climate in Liberia is tropical and humid. There are high precipitation levels, making the region uniquely suitable for intensive latex rubber, cocoa, and coffee cultivation, while territorial resources include mining reserves of gold, alluvial diamonds, iron, and most recently – offshore coastal oil reserves.

2.2. Demography and Diversity

Liberia has a population of nearly 4.1 million. Approximately 60% live in urban areas, and 43%

of the population is under 15 years of age. Prior to the Ebola outbreak, the median age of the

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population is 19 years old, and life expectancy is 60 among women) and 63 among men, but the immediate impact of the Ebola outbreak may have affected these estimates (Helleringer and Noymer 2015). The largest ethnic groups in Liberia include the Kpelle, Bassa, Grebo, Gio, Mano, Kru, Loma, Kissi, and Gola. Linguistic groups are typically correlated with “tribes” of the same name, and tribal identities are important aspects of social affiliation. English is the official language of Liberia, but 15 indigenous languages are officially recognized. Estimates of literacy among Liberians over the age of fifteen vary from 20-60%. Recent research suggests that some of Liberia’s linguistic diversity may be in decline due to urbanization, migration, and changes in formal and informal education systems (Childs 2015).

Liberia has a strong ethos of “Liberia for Liberians.” There are some large non-citizen permanent resident populations, like the Lebanese community, that have resided in Liberia for over a century, and are critical of constitutional legislation that prohibits their citizenship. Article V, Section 13 of the 1847 Constitution prohibited citizenship to all but “persons of colour.” In 1955, clause was changed to "Negroes or persons of Negro descent.” This clause likely also impacts the treatment of other minorities of non-African descent.

2.3. History of Liberia, Conflict, and Humanitarian Aid

The modern state of Liberia emerged in the 19^th century amidst concern from white Americans about the legal and social status of free people of African descent. They were convinced that post-slavery racial integration was an unrealizable goal in the United States, and founded the colony of Liberia as a free settler society that would exemplify the possibility of black self- governance. At its independence on July 26, 1847, Liberia was known as the second “Black state,” following Haiti, which gained independence in 1804. Early coastal settlements like Monrovia (named after the 5^th US President, James Monroe) were populated by freed American black slaves, and the settlements were linked together in a loose chain of commerce and exchange. Liberian settlements were dependent upon the American Colonization Society for food, equipment, weapons, and medical support, and the naval support of the United States government. For these reasons, Liberians colloquially refer to Liberia as “America’s stepchild.”

From 1808-1866, the United Kingdom established the Blockade of Africa, which intercepted slaving vessels and returned captured slaves to nearby African coastal regions. The population of Liberia expanded when British naval vessels intercepted slaving ships from central Africa and deposited the slaves in Liberian settlements. Settlers and their descendants were called Americo- Liberians, and new arrivals were called “Congoes.” Together, they formed an elite political, economic, and social class that ruled over the indigenous tribal groups that comprised 95% of the population of Liberia. Americo-Liberian social, religious, legal and political institutions formed the basis for the contemporary government of Liberia, and ethnic and religious competition for resources continues to function as a source of conflict. During the first 150 years of Liberia’s existence, the state gradually expanded through an assemblage of legal doctrines (The Laws and Regulations of the Liberian Hinterland), military actions (The Frontier Forces), missionary campaigns, and international territorial leasing agreements (e.g. with Firestone Corporation).

Social unrest grew under the rule of a self-serving oligarchy of Americo-Liberians.

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After a long period of authoritarian rule under President William Tubman funded by resource extraction arrangements and the financial patronage of other governments, conflict broke out under his successor, William Tolbert. The beginning of Liberia’s political and military destabilization began in April 1980, when Sergeant Samuel Doe launched a military coup d'état to topple the government of the First Republic, and install himself as President. The Liberian civil war officially began on December 24, 1989, when Charles Taylor, a former member of the Liberian government, began to seize much of the territory of greater Liberia with Libyan support.

During the subsequent thirteen-year conflict, the United Nations, the Economic Community of West African States (ECOWAS), and the neighboring states of Guinea, Sierra Leone, and Cote d’Ivoire became involved in the conflict. The Liberian war continued intermittently for thirteen years, and is estimated to have caused the deaths of 200,000-300,000 people, and to have displaced millions more across the region. In 1997, the international community, anxious about regional destabilization, secured a partial cease-fire among Liberia’s warring factions and installed the Interim Government of National Unity (IGNU). Soon after, Charles Taylor won a presidential election with a wide margin. Conflict resurged under Taylor’s despotic rule, and in 2003, the conflict was brought to an end through a negotiated peace settlement and the installation of a temporary government, the National Transitional Government of Liberia (NTGL) (McGovern 2005, Reno 2008).

From 2003 to the present day, the Government of Liberia (GOL) has worked in partnership with the United Nations Mission for Liberia (UNMIL), a peacekeeping and humanitarian assistance operation established by UN Security Council resolution 1509. At the outset of the partnership, UNMIL and its bilateral, multilateral, and NGO partners took a lead role in consolidating the territory of Liberia under UNMIL authority on behalf of the government of Liberia. UNMIL also took a lead role collaborating with the GOL to manage affairs of state, rebuild Liberia’s foreign relations, restore democratic elections in 2005, addressing national indebtedness issues, and delivering emergency humanitarian assistance to an impoverished, food insecure, and largely displaced population. From the period 2003-2007, nearly half of Liberia’s population was repatriated from refugee and IDP camps to largely destroyed urban centers and rural villages through a massive campaign that used the slogan “Home is best.” This massive period of displacement required the direct support of the population through humanitarian food, medical, housing, and cash disbursements in order to avert recurring public health crises, violence and instability, and a reversion to war.

The period of 2003-2005 also witnessed the repatriation of more than 120,000 combatants who had participated in all aspects of the Liberian war through the Disarmament, Demobilization, Rehabilitation, and Reintegration (DDRR) process, which exchanged cash and tuition or vocational training waivers in exchange for arms and the enlistment of individuals in an ex- combatant registry. In principle, all DDRR activities were required to include psychiatric and other mental health components, but in reality, the inability to identify a Liberian psychiatrist to lead the initiative resulted in the absence of any mental health or psychosocial screening during the DDRR process (Abramowitz 2014). Later, many ex-combatant initiatives hosted by international organizations or NGOs did include mental health and psychosocial components, but these initiatives cannot currently be traced through monitoring and evaluation documents that might speak to their utilization and efficacy.

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In 2005, the first national election since Charles Taylor’s 1997 election resulted in the election of Ellen Johnson Sirleaf, who campaigned on a platform of re-engaging with Europe, North America, and Asia; addressing Liberia’s critical debt burden; combatting gender-based violence;

and fighting corruption. This augured the onset of a rapid effort to shift authority from UNMIL to the Government of Liberia, despite many Ministries’ lack of management experience and uncertain mandates. The Liberian national army, police forces, and political parties had been temporarily disbanded for retraining; the international embargoes on Liberia’s leading cash exports (timber, diamonds, mining) as a result of wartime trade and ethics violations were in place; and the government was, essentially, broke.

Over the next eight years, from 2005-2013, President Sirleaf worked in partnership with the international community to negotiate large-scale debt forgiveness, re-equip various governmental ministries (Health and Social Welfare, Education, Gender), and bring peace and stability. As Liberia gradually assumed a greater burden of responsibility for managing its internal and external affairs with the continued strong support of UNMIL, and by extension, the UN Security Council, general conditions in the population slowly improved, but corruption remained a significant problem. However, at the end of this period, the majority of social services, food assistance, education services, and medical services were still provided by third-party humanitarian and development actors working in lieu of government service delivery.

During this time, many hundreds of Liberians were employed by international NGOs as “trauma healers” or “psychosocial agents” –a low-level staff or volunteer role for conducting recruitment, evaluation, counseling and community-based psycho-education. The training included empathic listening, basic education about post-traumatic stress disorder, anxiety disorders, and depressive disorders, basic counseling skills, and community outreach (Abramowitz 2014). Training processes for trauma healers and psychosocial agents have been criticized for their highly variable training, duration, supervision, and certification criteria. In some cases, personnel received ongoing training and supervision over many years from licensed mental health professionals. In most other cases, however, “trauma healers” and “psychosocial workers” were effectively unregulated and unsupervised; but were empowered by NGOs to conduct community-based education, outreach, and counseling after one-off brief (e.g. one-day, three- day, or one-week) training of trainers (TOT) initiatives.

Despite overall improvement, Liberia remained nearly at the bottom (175/187) on the Human Development Index in 2013. The inability of the healthcare sector to meet the pressing health needs of the general population was known to medical humanitarian programs; and the health sector was subject to recurring shocks, or epidemic outbreaks, throughout every year from 2003- 2014. The Ebola outbreak was by far the most severe of many epidemic shocks that destabilized the Liberian health sector. Its catastrophic impact upon the Liberian economy, health system, transportation, education system, and national and local revenues eclipsed previous crises. The Ebola outbreak also resulted in a temporary surge in humanitarian response to end the current outbreak, and repair the systemic gaps in the health sector that had allowed the outbreak to occur in the first place.

With the 2017 national elections on the horizon, and the pending closure of the United Nations Mission in Liberia, the key concerns for all Liberians are political and social stability, continuity

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of governance, economic revitalization, and the strengthening of the national health system, including national-level coordination and local access to care.

2.4. Political aspects (organization of state/government), distribution of power, contesting sub-groups/parties)

Liberia is centrally administered by a national government based in the coastal capital, Monrovia. At the local level, Liberia is divided into fifteen counties. Each county is administered by a superintendent appointed by the president and is further divided into districts, chiefdoms, and clans. The basic unit of local government is the town chief or committee of elders. The system of “native” administration retains much of the older system of indirect rule in which local chiefs collect taxes and judge minor cases, but the legal framework for this system is in flux.

Since 2005, Liberia has functioned as a constitutional democracy under the presidency of Ellen Johnson Sirleaf, winner of the 2011 Nobel Peace Prize, and the first female elected African president. An intensive international effort to support Liberia’s post-conflict reconstruction has been engaged in by the Liberian government in partnership with the United Nations Mission in Liberia (UNMIL), bilateral aid, and NGO-supported humanitarian assistance. The period of post- conflict reconstruction has seen marked improvements in life expectancy, maternal-infant health, economic and infrastructure development, and political stabilization, but institutions in Liberia remain highly dependent on foreign assistance and imported commodities, and highly vulnerable to shocks like the West African Ebola outbreak. The expatriate Liberian population living in North America and Europe contributes a high level of remittances and plays an important role in Liberian politics.

2.5. Religious aspects (religious groups, beliefs and practices)

Liberia is predominantly Christian, with approximately 85.6% of the population adhering to various sects of Christianity. Prominent denominations include: Lutheran, Baptist, Episcopal, Presbyterian, Roman Catholic, United Methodist, African Methodist Episcopal (AME), AME Zion, and a variety of Pentecostal and Seventh-Day Adventist congregations. Different sects of Christianity are known to correspond to different spheres of political influence and economic resources. An additional 12.2% of the population adheres to Islam, of whom a majority is Malikite Sunni, with Shia and Ahmadiyya minorities. Muslim populations are closely associated with Vai and Mandingo tribes, but are also known to be prevalent among Gbandi, Kpelle, and other ethnic groups. In addition, 1.5% claims no religion, and 0.6% follows indigenous religious beliefs. The remaining population identifies as Baha’i, Buddhist, Hindu, and Sikh (IRFR, 2014).

Sociocultural beliefs have intermixed with religious and indigenous practices in Liberia, blurring the distinction between religion and culture.

Despite the predominance of common religions, many Liberians incorporate aspects of indigenous religion − including secret societies, warrior cults, witchcraft, sacrifices to ancestors, reincarnation, and evil spirits – into their daily practices (Tolerance and Tension, 2010).

Traditional animistic cosmology holds that there are powerful spiritual forces that are neither good nor evil, but can be harnessed for political, economic, or social power, and harm or restore physical and mental health. Traditional forces must be engaged with carefully by following the

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rules of centuries-old men’s and women’s secret societies called Poro and Sande, or specific cults like Leopard or Snake societies, which are also responsible for religious initiation, circumcision, bush schools, and the administration of religious and spiritual rituals. Spiritual forces are considered powerful, but dangerous to tamper with, and can cause infertility, madness, or death, as can the commission of murder or theft, or being the victim of witchcraft or sorcery (Geschiere 1997). Many consult traditional religious healers, keep sacred objects in homes, and believe in the power of juju, all without asserting claim to traditional religions. Most Liberians believe that political and economic power is obtained, at least in part, through the manipulation of occult forces (Ellis and Ter Haar 2004). Traditional religious practices have been implicated in several murders associated with organ or body-part theft over the last two decades.

Liberia has no official religion, and its state constitution and laws generally affirm religious freedom. Public businesses and markets are encouraged to close on Sundays and Christmas (IRFR, 2014). Some Muslims report discrimination (Freedom House, 2014). Roughly 76% of Liberians in a survey believed that people of other faiths were free to practice their religion.

However, almost half of all Liberians surveyed believed that conflict between religious groups was a very big problem in Liberia (Tolerance and Tension, 2010). Specific religious beliefs and practices played a prominent role in community-based responses to the Ebola epidemic, especially around the issue of burials.

2.6. Economic Context and Social Structure

Liberia is one of the poorest countries in the world, with a per capita GDP of US$410 in 2013.

As of 2007, 88% of Liberians live on less than $1.25 per day, indicating high levels of absolute poverty (The World Bank Group 2015a). Liberia has the official World Bank status of a Heavily Indebted Poor Country and a United Nations classification as a Least Developed Country (The World Bank Group 2015b, United Nations 2015). Although official economic growth rates in 2014 were projected at 5.8% (The World Bank Group 2015c), the impact of the Ebola crisis has resulted in an economic collapse and food insecurity, and capital flight.

Liberia has rich natural resources and a climate that favors agriculture, but civil war has depleted the country's human capital and infrastructure, creating a heavy dependence on imports and foreign aid. Access to electricity, improved sanitation facilities, clean water supply, and year- round passable roads remains low. Current barriers to economic growth include inadequate infrastructure, poorly defined legal frameworks governing land administration, conflict between different ethnic groups, and low financial sector development. Liberians mainly find employment in the agriculture sector, which includes subsistence farming and industrial rubber, coffee, cocoa, and rice production. Employment is also found in trade and services, and a small sector of the economy is manufacturing and industry. The merchant marine industry is responsible for a significant allotment of both employment and revenue in Liberia (Government of Liberia 2015).

2.7. Marriage, Family, and Gender Relations

Households and communities in Liberia are highly organized by age and gender. From childhood through old age, men and women are socially organized into age cohorts. Older age cohorts have

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considerable authority over youth, and have the ability to make binding decisions about youth labor, education, marital choices, and healthcare. Youth are expected to be obedient and deferential to elders in an extensive kin network of obligation. A culture of “hypermasculinity”

likely contributes to a cultural context in which gender-based violence is highly prevalent, even pervasive (Jones et al. 2014).

Prior to the Liberian war, this paradigm governed marriage and family (Dunn-Marcos et al.

2005). According to Moran (1990), Liberian marriage customs, family life, and gender roles are closely associated with kin group classification as ‘civilized,’ ‘kwi,’ and Americo-Liberian; or

‘country,’ ‘uncivilized,’ ‘traditional,’ or ‘native.’ This informal classification has a substantial impact on how people organize households, families, economic responsibilities, and educational attainment, but there is considerable diversity between ethnic and religious groups, and across regions.

In the post-war period, social changes have undermined this system, leading to greater independence among youth, especially in urban areas. Today, in Liberia, 28% of women and 30% of men are married, and 30% of women and 24% of men are living together in informal unions (DHS 2013). Most households are multi-generational, and there is a widespread practice of child fosterage (22% of children were in household fosterage arrangements in the Liberian Demographic and Health Survey). Birth rates are rising rapidly in a context where children are highly valued, but infant and childhood mortality rates are high, and women have limited capacity to regulate family size. The process of childbirth itself is often handled by locally trusted traditional healers and midwives (Modarres and Berg 2016).

There has been a significant trend towards urbanization, with more than 50% of the Liberian population living in urban centers. The high levels of mobility, violence, and urbanization have shifted social relations within households, but domestic and sexual violence has reportedly substantially increased, even as households have consolidated and people have reentered schools and reassumed agricultural roles or other professions. In the course of this transition there appears to have been a gradual shift towards nuclear families, Christianization, and cultural urbanization, including the adoption of urban values, dress, lifestyles, and occupations, but many retain close connections to rural patterns of kinship, language, and dress. Status can be achieved through education, marriage, and professional attainment, but a dominant elite system makes upward mobility difficult. As a result, youth unrest is widespread, and youth movements and strikes occur frequently to bring attention to the lack of jobs, educational opportunities, and upward mobility for young men and women. Formal marriages are often monogamous, featuring nuclear family arrangements, and tend to occur late. Informal or “traditional” marriages are also widespread, and one may have serial traditional marriages in one’s life. People who self-identify as “traditional” live in rural areas, participate in a traditional gendered division of labor, are polygamous, and are often closely associated with specific market and agricultural practices (Moran 1990). In both ‘civilized’ modern households and traditional households, men and women contract informal extramarital unions with ‘girlfriends’ (also called ‘country wives’) or

‘boyfriends.’ Among Western-educated Liberians, marriage is contracted through legal and church-based ceremonies. Girls tend to socialize, date, and become involved with boyfriends prior to marriage. Marriage usually happens at a young age, between the ages of 16-18, but girls who receive higher education tend to defer marriage for longer periods of time due to policies

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that prohibit pregnancy within schools. In rural Liberia, polygamy is considered an ideal, and women may marry soon after menarche. The state recognizes both traditional marriages and

“modern”. Both are legal but rules are not the same for both and it is important, particularly for women, to understand that rights vary.

Among indigenous populations, marriage is to an extent a socio-economic venture in which the husband must pay the wife’s family a bride price and must perform bride service, or labor (Dunn-Marcos et al. 2005), but romantic love is becoming an increasingly important motivation for marriage in both rural and urban areas. In the event of divorce, the woman’s family is responsible for repaying the bride price and the husband receives custodial rights of their children, hence the Vai saying kai watamudengnda – a child belongs to his father (Olukoju 2006). Traditional custom dictates that the children of marriage belong to the husband and his family, but post-war Liberian legal reforms now grant custody to both parents. Relatedly, traditional custom mandated that upon the death of a male, all his assets (including children) revert to his family. Post-war legal reforms now mandate an equitable distribution of the deceased’s assets to spouse and children. These are seen as important legal reforms to advance gender equity.

While historically, gender roles are clearly defined within families and are associated with expected economic contributions, gender roles are in a state of radical flux in the aftermath of the Liberian war (Abramowitz and Moran 2012). Men are responsible for providing land, houses, and cash, and for clearing the land for agriculture and harvesting, along with performing hard labor activities such as making furniture or porting loads (Moran 1988, Dunn-Marcos et al. 2005, Fuest 2008). Since the end of the war, traditional women have become the dominant labor force in food production, responsible for 70% of cross-border trade (Diggins and Mills 2015). Urban women have assumed a greater role in politics, education, the NGO sector, and professional services (Fuest 2008). Across the board, women’s critical role has earned them the title of

“breadwinner” (Moran 1988). Prior to the war, however, women’s primary roles included food production, child rearing, and domestic work. The economic distribution of labor within households also varied by ‘civilized’ and ‘traditional’ status. In traditional households, women are more likely to participate in market activities, hold a certain degree of autonomy, and assume a relationship of gender complementarity within households. This contrasts with urban households, which feature gender dependency. Kwi women are often financially dependent upon men for cash, gifts, and support, and have less autonomy. They are also socially dependent on their husbands for status. A shift in economic activity, (e.g. from professional labor to market labor) could rapidly change a woman’s status from modern to traditional, and male family members (fathers, sons, brothers, and husbands) readily claim the products of her labor (Moran, (1986).

Many taboos, or cultural prohibitions, function to maintain social order and have positive health and social effects, and are heavily socially policed. General sexual taboos include those barring having sex with a pregnant woman or a woman who is still breastfeeding (Dunn-Marcos et al.

2005). Social taboos include using one’s left hand to greet people and hand over items, or selling food that has not been covered (Olukoju 2006). Some individuals and groups have specific rules regarding clothing that can be worn or food that can be eaten; and some medicines are believed to only work so long as individuals and family members observe specific rules.

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Because of changing social expectations within the household, domestic labor issues are a source of friction and can result in violence. Women are becoming increasingly resistant to husbands’, fathers’, brothers’, boyfriends’, and community leaders’ efforts to lay claim to their cash, labor, and other earnings, and this is an important cause of domestic disputes. Men may accuse women of being unfaithful with other boyfriends, and women may protest men’s spending of household cash on girlfriends or other family members. Women are expected to prepare food for their husband and children, and food is often withheld as a sign of displeasure with the marriage or as a suggestion of infidelity (Schroder 1974, Moran 1988).

The formal and informal education of children has also undergone major social changes. Girls are given household, cooking, and child-rearing tasks in order to prepare them for married life.

Boys are encouraged to seek labor or apprenticeships from an early age. School is difficult to access for both girls and boys, and school fees are a barrier to entry. With many men and women returning to high school and university education in the post-war period, access to financial resources for items like books, uniforms, school fees, and food is low, and demand is high. Men and women regularly have domestic conflicts over how limited financial resources are to be distributed for food, clothing, and educational expenditures for themselves and their children;

and who has the right to make these determinations. These conflicts are known to result in violence, and community leaders may have limited ability to intervene due to changing social expectations surrounding leadership and authority (Abramowitz and Moran 2012).

Parents and elders are closely involved in the upbringing of children, and strict disciplinary methods are used. Mothers and siblings play lead roles in disciplining younger children, and practices like beating, ‘peppering,’ and depriving of food are common disciplinary tactics.

Sibling ‘parenting’ responsibilities and expectations intensified in the context of conflict and life in refugee camps (Dunn-Marcos et al. 2005). Children conceived out of wedlock are not stigmatized; and a father may bring a child conceived out-of-wedlock into the household to be raised. However, children conceived during the war, especially as a consequence of rape, may be stigmatized by their own parents and by community members, and may be seen as having inherited ‘bad characters’ from combatant parents. Maternal-child attachment, postpartum depression, social rejection of the mother, and social rejection of the child have all been issues that have arisen for women who conceived children during the war.

‘Fosterage,’ or the practice of transferring children out of their parents’ households into family or community members’ households for childrearing, education, and labor, is a common practice in Liberian society, and it draws upon the belief that children are a shared resource, and that communities help to provide for families in times of trouble. Fosterage traditions provided important social supports during the Liberian War and during the Ebola epidemic. The practice of fosterage has been practiced in the region for many centuries, and it was most commonly known to occur when a family had more children than they were able to feed, and a relative or friend was childless. In this situation, the move of the child to a friend, neighbor, or family member was seen as contributing to the well-being of the child, the child’s parents, and the childless family (Moran 1992).

The practice of fosterage has ambiguous implications for physical and mental wellbeing. During the Sierra Leone and Liberian conflicts, child fosterage was used to accommodate major

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population displacement and instability issues (Shepler 2005), and it was also used as a model for child recruitment into armed forces (Coulter 2009, Utas 2008, for mental health implications see (Behrendt 2008)). While communities have been known to pool resources to send children to school, and fosterage can provide children with safe and loving homes where they have access to education, serious concerns are emerging around the use of child fosterage as a social coping mechanism. Before Ebola, fosterage was increasingly being recognized as a way to facilitate extreme uses of child labor in household, mercantile, and agricultural work, and there is a growing recognition that girls and boys are at a high risk for physical and sexual violence in fosterage situations. When the household needs for fosterage exceed available food, clothing, space, and labor resources, children may also be shifted between households many times, leading to instability and a lack of continuity in caregiving, access to health services, and educational access (Bledsoe, Ewbank, and Isugo-Abanihe 1988). Since the Ebola outbreak, communities have worried that the widespread demand for child fosterage was economically unsustainable, and they have demanded financial, psychosocial, and maintenance support for the fostered children of Ebola victims and Ebola child survivors (Abramowitz et al. 2015)

Elders are referred to as Uncle, Aunt, Mister, Mrs., Old Man, Papaye, Old Pop, or Old Lady, and are traditionally afforded great prestige. Respect for one’s elders is a core cultural value and as such elders are often cared for by children and may reside in the same home. If more than one generation lives in one house, the eldest male is considered the central authority figure. These extended family homes are often seen among traditional families, whereas nuclear families are more common among Western-educated homes. It is disrespectful for a child to shake hands with an elder (Dunn-Marcos et al. 2005). However, elder authority is often a source of community friction because elders may be seen as hoarding wealth, information, and resources from youth (Ellis 2001, Rowlands 2008); as using their authority illegitimately (Murphy 1980);

or as having been made irrelevant by recent post-war social changes (Sawyer 2005). New sources of authority are emerging through growing exposure to Western media, telecommunications, rising urbanization, and an increased value upon western education and urban employment. Practices in international development continue to call for consultation with community elders as a strategy for engaging community support in development projects in Liberia (Fearon, Humphreys, Weinstein 2009, Flomoko and Reeves 2012).

2.8. General health aspects

2.8.1. Mortality, threats to mortality, and common diseases

Health conditions are regarded as poor in Liberia, but in recent years, most measures of population-based health have been steadily improving, with continual improvements in the under-five mortality rate, maternal mortality ratios, and deaths due to HIV/AIDS and tuberculosis. Prior to the Ebola outbreak, life expectancy had reached 60-63 years from a postwar low of 43 years, but the probability of dying between the ages of fifteen and sixty is high (262/1000), suggesting that high mortality rates are not just ascribable to high infant and children under 5 mortality rates. Leading causes of death are acute respiratory infections, malaria, tuberculosis, HIV/AIDS, stroke, diarrheal diseases, maternal, neonatal, and nutritional causes, heart disease, chronic respiratory disease, and suicide, homicide, and conflict. There has been a steady improvement noted in all causes of mortality from 2000-2012. It is anticipated that many

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of these gains will have been temporarily reversed by the recent Ebola outbreak’s death toll and its resulting impact of diminished access to health services

2.8.2. Overview of structure of formal, general health system

The Liberian war destroyed the physical, logistical, and human resource infrastructure of the Liberian health system, and placed the Government of Liberia in a position of dependency on medical humanitarian aid. Since 2006, health systems strengthening has been a key priority for Liberia’s MoHSW, but Liberia remains dependent upon foreign aid for the delivery of primary and tertiary healthcare (WHO 2015). The Ebola epidemic revealed that health systems strengthening requires a greater investment in all aspects of health systems functioning (healthcare worker (HCW) training, surveillance, reporting, analysis, policy, financing), and that post-conflict investments focused on primary healthcare to the exclusion of all other factors. This has prompted a major structural overhaul that included a planned comprehensive restructuring of the Liberian health sector bureaucracy. This restructuring would be largely funded through extramural funds.

The Liberian health sector is funded through the Liberian national budget and direct bilateral and multilateral grants, all of which is funneled through the Pool Fund, a financing mechanism established under the 2007 National Health Plan to centralize international fund allocations and facilitate the nationalization of healthcare priorities. The National Health Plan called for the decentralization of the Liberian health sector. The purpose of the innovation of The Pool Fund is to allow the MoHSW to realize efficiencies by bypassing the need for multiple parallel grants and projects, allow the MOHSW to direct the allocation of funds in direct partnership with international NGOs, and allocate resources to nationally identified priorities (Lee et al. 2011). It provided a blueprint for the development of primary, secondary, and tertiary levels of healthcare;

and legislated the suspension of user fees. It also committed the Liberian government to increasing total national budgetary commitments to health expenditures to 15% of the national budget (Lee et al. 2011). The official policy for health sector redevelopment has been to expand primary health care access and to decentralize health care administration to County Health Teams (CHTs) lead by a County Health Officer, who reports to the Minister of Health.

Current policy indicates that mental health care is to be fully integrated into the Liberian primary healthcare system. Funding for mental health is a legislative mandate, but it has taken a low priority relative to other health expenditures. Mental health financing has a low priority. In a 2009 policy exercise designed to develop realistic financial cost estimates for the basic package of health services, mental health services were allocated US $0 (RBHS 2009). However, significant steps have been taken to build a ‘Coordinated Care’ approach that integrates mental health into primary health care (c.f. collaborative care). (Patel et al. 2013)

A central component of Liberia’s health policy is the Basic Package of Health Services (BPHS), which assures maternal and newborn health, child health, reproductive and adolescent health, communicable disease control, mental health, and emergency care (MOHSW 2008). However, the BPHS explicitly notes that “Several major areas of concern, even those of particular concern in the post-conflict environment such as mental health, were either excluded for the time being, or have been accorded lesser priority” because they do not advance MOHSW priorities of

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decreasing morbidity and mortality; deploying safe, effective, and available interventions; are not feasible given Liberia’s resources and constraints; or lack the potential for medium- to long- term sustainability (MOHSW 2008, 5). The main focus of the Liberian MoHSW has been the training and expansion of a health professional workforce in mental health diagnosis, treatment, and referral; and the expansion of diagnosis and mental health referral best practices. Local and international NGOs have been working with the MoHSW to secure a regular supply of commonly needed psychiatric medications on the Essential Drug List. A 2011 report on the basic package of essential services also prioritizes the growing need for mental health and substance abuse services, but as of 2011, access remains low (MOHSW 2011a, 2011b), with just 18% of clinics offering any form of mental health services. Most primary healthcare facilities run by international NGOs do not include mental

health in their programming.

Compared to other countries in the region, healthcare service utilization is relatively low due to a lack of access to supplies, equipment, and staff in healthcare facilities—recent analyses from Liberia’s MoHSW suggest that 41% of all households (15% urban and 61%

rural) did not have access to a health facility.

Recent evaluations of healthcare access further indicate that local populations have lowered health facility utilization and low confidence in the formal healthcare sector due to a fee- for-service system implemented during the health sector transition. Even so, in recent years, the Liberian government had made significant strides in primary health care delivery. In 2010, 80% of government facilities were ready to provide the Basic Package of Health Services, and the healthcare workforce had tripled from 3,107 in 2003 to 9,196 in 2009 (Lee et al. 2011). The MoHSW has also revitalized nursing and midwifery training through the Martha Tubman School of Midwifery in Grand Gedeh County, the Esther

Bacon School of Nursing and Midwifery in Lofa County, and the Tubman Institute of Medical Arts in Monrovia. The largest hospital in Liberia is John F. Kennedy (JFK) Hospital in Monrovia, which is financed and administered by the MoHSW.

The majority of the primary and secondary healthcare facilities in the country continue to be administered by foreign aid organizations. Clinics and hospitals administered by the state are seen as providing an inferior standard of care, often due to the imposition of a pay-for-service or cost-offset system that discourages utilization, even in cases of emergency. Access to healthcare in Liberia is understudied, but one 2008 study of essential health services in Nimba County reports on barriers to healthcare and healthcare utilization practices in a region where

Figure 1: Liberia Burden of Disease (WHO 2015)

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humanitarian health services have been made available to offset limited public health sector services. In Nimba County, a densely populated region on the border of Cote d’Ivoire and Guinea, Kruk et al. (2010) found that residents had to travel an average of more than two hours to reach any health facility, while in each village, there was an average of 2.3 village healers (Kruk et al. 2011). Another study of confidence in healthcare in Nimba County found low rates of confidence in access to healthcare among rural populations (Svoronos, Macauley, and Kruk 2014). Respondents who used health services used both traditional healers and available primary and secondary health services. All respondents could access malaria treatment at that facility, but only 55% could access HIV testing, 26.8% could access emergency obstetric care, 14.5% could access care for pediatric illnesses, and 12% were able to access mental health services. Essential infrastructure investment has been focused on primary clinics, but substantial underinvestment in public health, epidemiological and emergency response capabilities has been identified as a factor in the inability of the health system to manage the 2014-2015 epidemic outbreak.

A recent study of over 100 Liberians with physical and mental disabilities found that individuals confronted major challenges obtaining support through informal networks (Cooper and Libanora 2016). Community-based rehabilitation services are not integrated with mental health services, and mental health services tend to be concentrated in highly populated areas like Montserrado County, where the capital city Monrovia is located. The study also found that 62% of all respondents had difficulty accessing mental services when they needed them. While a relatively high proportion of respondents in this study’s sample were taking medications--respondents with mental health (76%) or epilepsy (97%) disabilities were taking medications--it also found that these individuals had difficulty accessing medications.

Traditional healers include herbalists, bonesetters, midwives, diviners, and other types of religious healers (Schoepf and Guannu, 1981). In a context of rising Pentecostalism in Liberia, they may also include faith healers, pastors and prosperity gospel preachers. In the formal healthcare sector, access to care is limited and inconsistent. This problem is exacerbated by the fact that the majority of public health care services are funded through international funds, which are subject to external pressures, timeline and allocation restrictions, and fluctuations in the global demand for humanitarian health services. Some researchers believe that the traditional healing sector is frequently characterized by secrecy, authority, and distrust of the healthcare system (Lori and Boyle, 2011), while others suggest that traditional healers and local midwives are highly trained and experienced and much more caring than nurses and doctors at hospitals and clinics, but are unfairly excluded from the formal healthcare sector by specific training and educational barriers (Modarres and Berg 2016).

3. MENTAL HEALTH AND PSYCHOSOCIAL CONTEXT

3.1. Epidemiological studies of mental disorders and risk/protective factors conducted in the country

Mental illness has been long studied in Liberia, but little past medical or anthropological literature is available for review (Nolan 1972, Thébaud 1982). The medical anthropological and transcultural psychiatric study of Liberian culture and mental illness seems to have been effectively disrupted from 1985-2007. Even with the resumption of research activities in Liberia

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post-war, there has been little research on the distribution of severe psychopathology, mental disorders, and risk/protective factors in Liberia, and there was an absence of reliable public health data to inform the Global Burden of Disease (GBD) Report.

Research on mental illness in Liberia has focused on the burden of post-traumatic stress disorder (PTSD) and other common mental disorders (e.g. depression, anxiety disorders, suicidality) in populations most affected by conflict, and on exposure to traumatic events like combat or sexual violence.¹In one study of an area highly affected by violence, murder, or battle, 48% of respondents reported symptoms of PTSD (Galea et al. 2010), which tracked closely along the geographic path of battle. This estimate is in line with a previous study that found that 44% of respondents met symptom criteria for PTSD, 40% met criteria for major depressive disorder, 10% reported suicidal ideation, and 8% met criteria for social dysfunction (Johnson et al. 2008).

A study of Liberian refugees in the Oru refugee camp in Nigeria found that among a fairly small sample of 200 refugees, 60% reported a sufficient number and severity of symptoms consistent with PTSD (Olubunmi and Dogbahgeen 2013). Two studies of PTSD among Liberian refugees identified minor variations in expected PTSD symptom structure (Rasmussen, Smith, and Keller 2007, Vinson and Chang 2012).

A more recent study of youth mental health needs in Monrovia predictably found that war exposure and post-conflict sexual violence, poverty, infectious disease, and parental death negatively impacted youth mental health and functionality in education, employment, and positive social relationships (Borba et al. 2016).

There are also very few studies of substance abuse among Liberian populations. A study of substance abuse among Liberian adolescents found that 50% of respondents had used alcohol, 9% had used marijuana, and that all adolescent substance users were more likely to engage in risky sexual behaviors (Harris et al. 2012). One study of frequent alcohol users found that frequent alcohol use was correlated with decreased healthcare seeking behaviors and extreme poverty (Weil et al. 2014); and another found that ex-combatants were more likely to abuse alcohol, suggesting a possible attempt to self-medicate mental illness (Johnson et al. 2008).

Abramowitz’s (2014) ethnography describes the use of marijuana and diazepam by war-affected youth to manage symptoms of PTSD and depression.

Severe psychiatric morbidity issues were found among ex-combatants (Johnson et al. 2008) and among children formerly associated combatant groups in Nimba County (Behrendt 2008). The persistence of PTSD may be associated with continued exposure to extreme stress in a context of chronic stressors like post-conflict instability, poverty, food insecurity, and sickness (Galea et. al.

2010). Johnson et al. also identified traumatic brain injury as a possible widespread complication among ex-combatant populations and may confound efforts to diagnose mental illness at the community level (Johnson 2012). There are almost no resources across Liberia to address what may be a high burden of neurological disorders, including traumatic brain injury.

According to the UNDP, almost everyone experienced or witnessed atrocities during the war (UNDP 2004), including murder, rape, and physical abuse. Sexual violence, rape, and atrocities

1These data are largely derived from population-based psychiatric epidemiological research using self-report symptom checklists. Trained diagnosticians have not clinically validated these reports.

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during the war and post-war period have reportedly, been rampant, fueled by a culture of

‘hypermasculinity’ (Vinck and Pham 2013, Lekskes, van Hooren, de Beus 2007). High rates of sexual violence, transactional sex, and “chronic exposure to sexual violence” persist, are worsened by poverty and instability, and are believed to impact women’s risk of sexually transmitted infections (Callands et al. 2013, LISGIS 2008). These risk factors are likely to create vulnerabilities to long-term mental disorders (Jones et al. 2014). Swiss et al (1998) found a high rate of reported incidences of sexual violence, coercion, and torture, with 49% of all participants reporting at least one act of physical or sexual violence (Swiss 1998). Wartime statistics on rape have been the subject of methodological critique (Palermo and Peterman 2011), but high levels of wartime and post conflict sexual violence rates have been confirmed in subsequent studies (Johnson et al. 2008), as have persistent/chronic PTSD over time. In Johnson et al.’s study, both male and female ex-combatants were many times more likely to have been exposed to sexual violence and to experience PTSD. The mental health legacies of wartime sexual violence across the region have been qualitatively described (Liebling-Kalifani et al. 2011, Coulter 2009).

The mental health and psychosocial burdens caused by the recent Ebola epidemic remain unstudied, but are presumed to be high enough to warrant serious policy attention (Van Bortel et al. 2016, Schutz et al. 2015). Studies conducted in Nigeria during the recent Ebola outbreak found that the psychosocial effects of the Ebola epidemic included adjustment disorders, symptoms of anxiety, and depression (Mohammed et al 2015a, 2015b, 2015c). In Ebola patients, delirium was common at the end-stage of the disease, creating complications for containment of highly infectious patients. Some mental health experts have observed mental disorders like depression, anxiety, and post-traumatic stress disorder, vision problems, blindness, chronic joint pain, and possible neurological complications in Ebola survivors which may be part of an emerging discussion on “post-Ebola syndrome” (Kutalek2014, Grady 2015).

Baseline mental healthcare, including psychosocial counseling, was integrated into Ebola case management, requiring a major scale up of Liberia’s mental health and psychosocial response systems capacities. The integration of psychosocial counseling into Ebola case management had important effects. It reduced conflict, facilitated behavior change, helped families and communities respond to quarantines and deaths, strengthened reporting systems, and created important bridges to survivor reintegration. However, case management plans may have failed to take into account two key issues that have had import for post-Ebola mental health: (1) how to respond to the specific (and overwhelming) mental health needs of survivors; and (2) how to respond to fear as a social contagion effect (Thomas 2015, Cheung 2015) during a major epidemic. Anti-stigma activities were likely effective – a national Knowledge, Attitudes, and Practices study conducted in November 2014 found that close 100% of respondents believed that Ebola was real and found that 90% of respondents would welcome Ebola survivors back into their communities—but it also found that 50-60% were concerned that they could still be infected by a survivor. As indicated earlier, communities that were highly affected by Ebola in Monrovia reported a need for psychosocial support for child Ebola survivors and were certain that children would need counseling and trauma-healing (Abramowitz et al. 2015).

Culture and Mental Health in Liberia: A Primer 2017